Fillable Complete all applicable items. Type or print legibly. (North Dakota State Electrical Board)

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• Complete all applicable items. Type or print legibly.
• $50.00 application fee* (check or money order) made payable to ND State Electrical Board (NDSEB) must
accompany this application.
*Note: A separate licensing fee will be required upon passing the exam or endorsement approved.
• Work Experience must be completed as follows:
o Minimum of 6,000 hours for Power Limited Electrician.
o If self-employed need minimum hours of prior work experience.
o Re-Exam, list your current employer, if not employed list N/A.
• Employment verification (SFN 11845) must accompany this application – not required for re-exam.
Name (First, Last)
Social Security Number
Date of Birth
Mailing Address
City
State
ZIP Code
Cell Phone Number
Email Address
Active Member of the Military
☐ No ☐ Yes
Spouse of a Member of the US Armed Forces or Reserve
☐ No ☐ Yes
Endorsement Requested
☐ No ☐ Yes - Enclose a Valid Board Recognized Tradesman Certificate
Graduated from High School or Received a GED
☐ No ☐ Yes
Completed or Graduated from a Power Limited Program
☐ No ☐ Yes - Name of Program
Registered with the NDSEB as a Power Limited Apprentice
☐ No ☐ Yes
Registered or Licensed with the NDSEB
☐ No ☐ Yes
Registered or Licensed in a State Other than North Dakota
☐ No ☐ Yes – Where?
Ever Been Convicted of a Felony Under the Laws of this State or any Other Jurisdiction?
☐ No ☐ Yes - Explain fully on a separate sheet of paper
Present Employer
City
State
Work Experience
Employment Dates
Est. Hours Worked
Previous Employer
City
State
Work Experience
Employment Dates
Est. Hours Worked
License Type and Fee
Power Limited Electrician - $50.00
By
☐ Examination ☐ Endorsement
Re-Exam
☐ No ☐ Yes - Submit Application and Fee Only
SFN Need # (11-2020)
Page 2 of 3
Previous Employer
City
State
Work Experience
Employment Dates
Est. Hours Worked
Previous Employer
City
State
Work Experience
Employment Dates
Est. Hours Worked
Previous Employer
City
State
Work Experience
Employment Dates
Est. Hours Worked
Previous Employer
City
State
Work Experience
Employment Dates
Est. Hours Worked
Previous Employer
City
State
Work Experience
Employment Dates
Est. Hours Worked
Attach Additional Work Experience if Needed
I authorize investigation and certify that all statements contained in this application are true and accurate. In compliance
with the Federal Privacy Act of 1974, the disclosure of the individual’s social security number on this form is mandatory
pursuant to North Dakota Century Code 43-50-02. The individual’s social security number is used for identification and
verification purposes. Penalty for the applicant not including the social security number on their application will cause the
application to not be processed.
Applicant Signature
Date
Submit completed application to:
North Dakota State Electrical Board Phone: 701-328-9522
PO Box 7335 Fax: 701-325-9524
Bismarck, ND 58507 Email address: electric@nd.gov
Website: www.ndseb.com
SFN Need # (11-2020)
Page 3 of 3
FOR OFFICE USE ONLY
Employer
Experience Credit
Hours
Jurisdiction
TOTAL
Certification Agency
Completion Date
Re-Exam
Date
Score/Waiting Period
☐ Approved ☐ Denied
For
☐ Examination ☐ Endorsement
Approved By
Date
Exam Date
Exam Score
License Number
Date Issued
• Each employer must verify work experience separately. Please make copies as necessary.
• Verification of hours must be on this form to be acknowledged; any other forms of verification will not be accepted.
• Employment verification must accompany the Application for Electrician’s License by Exam (SFN 11858) or Application for
Power Limited Electrician’s License (SFN 61903).
Experience Requirements:
• Master: 10,000 hours (one year and 2,000 hours if ND Journeyman).
• Class B: 3,000 hours (farmstead and residential wiring only).
• Journeyman: 8,000 hours.
• Provisional Military Spouse: Experience for at least two of the four years preceding the date of application.
• Power Limited: 6,000 hours.
Name of Applicant (First, Last)
Last 4 of Social Security Number
Address
City
State
ZIP Code
Name of Electrical Contracting/Power Limited Business
Address
City
State
ZIP Code
Master/Power Limited Name
Master/Power Limited License Number
Position Held by Applicant
Dates of Employment
Start Date: End Date:
Total Hours of Electrical/Power Limited Work
Dates Above Taken from Payroll Records
☐ Yes ☐ No - Explain
Work Completed in the State of North Dakota
☐ Yes ☐ No - Attach a List of Jobs, if Jobs were Inspected by a Governmental Authority and if a License was Required
I declare under the penalties of perjury that this employment verification is to the best of my knowledge and belief a true, correct, and
complete record.
Signature of Contracting Master/Power Limited Electrician in Presence of Notary
Date
State of
County
Before me, a notary public in and for said county/state, the NAMED PERSON below, personally appeared before me to be the same
person who executed the within and foregoing document and he/she acknowledges to me that he/she executed the same.
On this day:
Date
Name(s) of Individual Making Statement (By)
Affix Notary Stamp
Signature of Notary Public or Other Authorized Officer
Commission Expiration Date (if not listed on stamp)
North Dakota State Electrical Board Phone: 701-328-9522
PO Box 7335 Fax: 701-328-9524
Bismarck, ND 58507 Email address: electric@nd.gov
Website: www.ndseb.com
EMPLOYMENT VERIFICATION
NORTH DAKOTA STATE ELECTRICAL BOARD
SFN 11845 (12-2020)
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Completed 21 April 2021

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